Failure of endovascular stenting for popliteal cystic disease

We describe an attempted endovascular stenting for popliteal artery stenosis secondary to adventitial cystic disease in a 56-year-old man with lifestyle-limiting claudication. Despite technical success, it remained patent only for 1 week, requiring interposition venous graft reconstruction eventually.     

Prevention of mother to child transmission of HIV infection in Pacific countries

Introduction: A generalized epidemic of HIV infection has been evolving in Papua New Guinea over the last decade, whereas in other Pacific Island countries and territories (PICT) HIV transmission has generally been less widespread. Programmes to detect HIV infection in pregnant women and to prevent mother to child transmission (MTCT) during either delivery or breast‐feeding can decrease the incidence of infection in infants. The limited health infrastructure present in some PICT may delay the implementation of effective programmes to decrease MTCT of HIV. Methods: We used a standardized questionnaire to survey health‐care providers in 22 PICT for information on the epidemiology of HIV infection and strategies used during 2004 to prevent MTCT of HIV infection in their country. We supplemented these survey responses with data obtained from regional organizations supporting national responses to HIV. Results: We obtained responses from 21 PICT. The reported prevalence of known HIV infection was >150 per 100 000 persons in Papua New Guinea, approximately 100 per 100 000 persons in French Polynesia, Guam, New Caledonia and Tuvalu and <50 per 100 000 persons in the remaining 14 PICT. Other than in Papua New Guinea, where an estimated 500 pregnant women had HIV infection diagnosed in 2004, reported HIV infection among pregnant women was rare. Ten PICT reported that an HIV antibody test was offered as a routine component of antenatal care and 11 reported that antiretroviral medications were available for the prevention of MTCT of HIV infection. Conclusion: The prevalence of HIV infection differs greatly between PICT with a varying risk of MTCT of HIV infection. Successful prevention of MTCT of HIV infection throughout the PICT will require improved uptake of antenatal HIV antibody testing and better access to antiretroviral medications.     

Hemorrhoids in pregnancy

QUESTION One of my patients is in the third trimester of her first pregnancy. She has recently experienced spotting during her bowel movements. She has hemorrhoids. What medications are safe?ANSWER The treatment is mainly symptomatic for most patients. Most forms of the condition can be treated by increasing fibre content in the diet, administering stool softeners, increasing liquid intake, and training in toilet habits. Although none of the topical antihemorrhoidal agents commonly used have been assessed for safety in pregnancy, it is unlikely that the constituent parts (anesthetic, corticosteroids, and anti-inflammatory agents) will harm the third-trimester infant. In most women, most symptoms of the condition will resolve spontaneously soon after giving birth.     

Is early primary repair for correction of tetralogy of Fallot comparable to surgery after 6 months of age?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether early primary repair for correction of tetralogy of Fallot (TOF) resulted in better outcomes than surgery after 6 months of age. Altogether 650 relevant papers were identified using the below mentioned search, eight papers represented the best evidence to answer the specific question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that early primary repair of TOF has been shown to be comparable to later repair, with several retrospective series concluding that there is no increase in mortality with children under 6 months of age. Freedom from reintervention has also been shown to be similar irrespective of the age primary repair is undertaken. However, it has been observed that length of intensive care unit stay, period of mechanical ventilation and the need for inotropes is increased in patients undergoing primary repair at <3 months of age.     

The Fetal Safety of Hydrocortisone-Pramoxine (Proctofoam-HC) for the Treatment of Hemorrhoids in Late Pregnancy

ObjectiveFetal safety has never been studied for any drug used in the treatment of hemorrhoids. Proctofoam-HC is a combination of a corticosteroid and a local anaesthetic that is proven effective for the treatment of hemorrhoids. The objective of this study was to assess prospectively the fetal safety of third trimester exposure to Proctofoam-HC.MethodsIn a multicentre study, 240 women exposed to Proctofoam-HC in the third trimester and a similar number of control pregnant women were followed up postnatally.ResultsWhen compared to controls exposure to Proctofoam-HC was not associated with any adverse fetal effects on birth weight, gestational age, rates of prematurity, or pre- or postnatal complications.ConclusionProctofoam-HC is safe to use in the treatment of hemorrhoids in late pregnancy.     

Considering complementary and alternative medicine alternatives in cases of life-threatening illness: applying the best-interests test

In this article we explore decision-making about treatment when a child faces a life-threatening illness but conventional treatment presents substantial risk and uncertain benefit. When is it acceptable for parents to decide to use complementary and alternative medicine as an alternative, rather than a complement, to conventional care? We use the example of a young child suffering from progressive glycogen storage disease, for whom liver transplant offers the only prospect of a cure. Without a liver transplant, the disease usually results in death within a few years. However, experience using transplant to treat this illness has been limited, success is far from ensured, and the risks (including death and continued progression of the disease) are substantial. The child's parents, who are first-generation immigrants, consider the risks of the transplant unjustified because it still does not offer good prospects for a healthy future. They believe that traditional Chinese medicine could help remediate their daughter's disease. In the article we (1) review parents' obligation to make treatment decisions in the best interests of their child, (2) explain limits on parents' decision-making authority, (3) explore how "best interests" are determined, focusing on cases of serious illness for which conventional treatment is risky and benefit is possible but uncertain, (4) explain the standard of care that physicians must meet in advising about treatment, and (5) outline factors that clinicians and parents should take into account when making decisions.